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JME Digest | June 2018

In this month’s JME Digest, we will be covering:

Antommaria, A. and Prows, C. (2018) ‘Content analysis of requests for religious exemptions from a mandatory influenza vaccination program for healthcare personnel’, Journal of Medical Ethics, vol. 44, pp. 389-391

MacCormick, F. et al (2018) ‘Resuscitation decisions at the end of life: medical views and the juridification of practice’, Journal of Medical Ethics, vol. 44, pp. 376-383

Antommaria and Prows

Vaccinating healthcare personnel against influenza is considered important for myriad reasons. As such, Antommaria and Prows note that some healthcare systems have adopted mandatory vaccination, which has led to professional societies recommending mandatory vaccination programmes where voluntary vaccinations do not reach 90%. These programmes, naturally, permit medical exemptions. They also permit religious objections to vaccinations, though there are very few. The authors’ study aims to characterise requests for religious exemption in these mandatory programmes.

The study took place in Cincinnati Children’s Hospital Medical Center, which introduced mandatory influenza vaccinations for staff in 2007. Religious accommodations require an application form detailing reasons, including the duration the applicant has held their beliefs, and supporting documentation. These exemptions also require annual renewal. The study examines religious accommodations from the 2014/15 influence season, in which just 12 of 15,140 employees applied for religious exemptions - all were granted.

Those employees had held their religious beliefs for between 8 and 30 years, with an average of 17. They also volunteered information as to their religious affiliation even though this was not a requirement. Some also provided signed letters from their religious leader.

Antommaria and Prows analysed the applications, and coded objections into six reasons: risk/benefit, ethical/political, lack of direct patient contact, providence, purity (with one referring to the vaccination as ‘unnatural and invasive’), and sanctity of life. Whilst some applicants gave just one reason, others gave multiple, with two applicants providing five reasons.

The authors conclude that permitting religious exemptions does not necessarily undermine mandatory influenza vaccination programmes. In the case analysed, just 0.08% of employees applied and received religious accommodations. They also note that partnering with religious leaders and groups does help address religious objections to vaccinations, as it results in the provision of credible information which can dispel rumours and reduce resistance. Some objections were based on false “facts”, such as the influenza vaccine containing cells from aborted human foetuses, so ensuring people are suitable informed is important.

MacCormick et al

GMC guidance states that doctors should always work with the patient or their relative(s) when making decisions regarding DNACPR. A 2014 case clarified this duty of clinicians. Where CPR is considered futile by doctors, patients must be informed of this and made aware of the fact they have a right to a second opinion.

MacCormick et al conducted ethnographic research to consider the reality of DNACPR decisions and the involvement of patients/relatives. Three key themes emerged: informing or involving (whose decision, ultimately, is resuscitation?), challenges in making DNACPR decisions, and consequences for patient care.

Doctors commented that there is now more communication with families than previously. They found failure to inform patients and relatives led, rightfully, to distress, however some still did not fully discuss resuscitation. In some instances, patients were left unsure of what they were told about DNACPR, which MacCormick et al believe means they ought to have been more involved, and certainly more informed. Some doctors appeared to hold the belief that resuscitation was a solely medical question, and that simply informing patients and relatives of a decision already made was enough. Other were confused as to what exactly it means to involve the family.

The main challenge in making DNACPR decisions was doctors finding it difficult to have the discussions with patients and relatives. Particularly when they do not know the patient well, they felt they would rather wait until they get to know them rather than soon after admission. However, waiting to get to know a patient presents the risk of their condition deteriorating before resuscitation has been discussed.

These problems may result in delayed decision making, which affects patient care. Doctors are reluctant to complete DNACPR forms out of fear of complaints, meaning where this would have been done as a medical decision previously no decision is being made. In one case, a patient had no close family for doctors to consult, resulting in the consultant refusing to sign the form. Timing appeared to be a big concern of doctors; where hard discussions had already taken place, doctors were reluctant to then begin discussions concerning resuscitation, and some would rather delay decisions to take account of patients’ feelings. Waiting to have these discussions, however, could result in inappropriate and unwanted resuscitation.

MacCormick et al fear that the juridification of healthcare is going to lead to the narrowing of professional autonomy. This, in turn, may negatively impact on the quality of care at the point of delivery.

Against Religious Exemptions in the United States